Employer’s Wage Claim Response Form
Oklahoma Department of Labor
www.labor.ok.gov
Before completing this form PLEASE READ ALL INSTRUCTIONS printed on reverse side
1. CLAIMANT NAME
EMPLOYER
FILE DATE
2. NAME OF BUSINESS
TELEPHONE
3. BUSINESS ADDRESS
CITY
STATE
ZIP CODE
4. POINT OF CONTACT NAME
TELEPHONE
ADDRESS
CITY
STATE
ZIP CODE
5. FEDERAL ID NO.
IS THE BUSINESS INCORPORATED?
☐ YES ☐ NO
ANNUAL DOLLAR VOLUME
6. COMPANY PRESIDENT/OWNER
TELEPHONE
ADDRESS
CITY
STATE
ZIP CODE
7. COMPANY VICE PRESIDENT/MANAGER
TELEPHONE
ADDRESS
CITY
STATE
ZIP CODE
8. COMPANY SECRETARY/TREASURER
TELEPHONE
ADDRESS
CITY
STATE
ZIP CODE
9. SERVICE AGENT
TELEPHONE
ADDRESS
CITY
STATE
ZIP CODE
10. IS THE CLAIMANT RELATED TO OWNER/OFFICER OF BUSINESS?
☐ YES ☐ NO If yes, what is the relationship?
11. IS BUSINESS STILL OPERATING?
☐ YES ☐ NO
CURRENT NUMBER OF EMPLOYEES
12. IF BUSINESS IS CLOSED, HAS ANY ACTION BEEN FILED IN BANKRUPTCY COURT?
☐ YES ☐ NO Trustee’s Name: _______________________________________ Case #: ________________________________
Trustee’s Complete Address: ________________________________________________________
Bankruptcy Attorney (if any): _____________________________ Contact Telephone: _________________________________
13. LIST OTHER BUSINESSES OPERATED BY CORPORATION OR OWNER
EMPLOYMENT AGREEMENT
14. WHO HIRED CLAIMANT?
DATE OF HIRE
15. CLAIMANT’S STARTING EMPLOYMENT DATE
LAST DAY OF EMPLOYMENT
16. WHAT WAS AGREED PAY PERIOD? (ATTACH PAYROLL RECORDS)
17. WHAT WAS AGREED RATE OF PAY (If more than one type of wage, fill in
each amount AND attach supporting documents)
$_____________________REGULAR
$_____________________COMMISSION
$_____________________MINIMUM WAGE
$_____________________BENEFITS
$_____________________OVERTIME
$_____________________MISC.
USE THIS SPACE TO EXPLAIN:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Oklahoma Dept of Labor
3017 N Stiles, Suite 100
Oklahoma City, OK 73105
405-521-6100
888-269-5353
[email protected]
18. WAS AGREEMENT
☐ ORAL ☐ WRITTEN (ATTACH COPY)
DOES CLAIMANT HAVE ANY OF YOUR PROPERTY?
☐ YES ☐ NO If yes, explain:
19. DID CLAIMANT SIGN ANY DOCUMENTS AUTHORIZING DEDUCTIONS OTHER THAN REGULAR PAYROLL DEDUCTIONS?
☐ YES ☐ NO If yes, enclose copy and explain
20. IF CLAIM IS FOR HOURLY WAGES OR SALARY, DID CLAIMANT WORK WEEKS/DAYS/HOURS AS CLAIMED?
☐ YES ☐ NO (Attach copies of time cards and other records)
Explain:
21. IF CLAIM IS FOR HOLIDAY, VACATION, OVERTIME, SEVERANCE, BONUSES, OR OTHER SIMLIAR ADVANTAGES OF PROMISED PAY, DO YOU HAVE A
POLICY OR PRACTICE SPECIFIC TO SUCH PAYMENTS?
☐ YES ☐ NO (Attach copies of any written policies or agreements, including Claimant’s signature page acknowledging receipt and understanding, if
it exists)
22. DID CLAIMANT MEET CONDITIONS OF SUCH POLICIES OR PRACTICES?
☐ YES ☐ NO
Explain: ___________________________________________________________________________________________________________________________
23. HAS CLAIMANT BEEN PAID ANY OF WAGES IN QUESTION? ☐ YES ☐ NO
If yes, indicate gross amount paid: _________________________ (Attach copies to verify payment, i.e. certified checks copied front and back)
Date Paid: __________________ ☐ Cash ☐ Check ☐ Other, explain ________________________________________________________________
24. WHAT GROSS AMOUNT DO YOU ACKNOWLEDGE IS OWED CLAIMANT?
_______________________________________________________________________ (Attach check in that amount made payable to claimant
NOTE: If wages are due, payment must be IMMEDIATE in accordance with Title 40 O.S., Section 165.3(B): “If an employer fails to pay an
employee wages [at the regularly designated payday established for the pay period in which the work was performed], such employer shall
be additionally liable to the employee for liquidated damages in the amount of two percent (2%) of the unpaid wages for each day upon which
such failure shall continue after the day the wages are earned and due if the employer willfully withheld wages over which there was no bona
fide disagreement; or in an amount equal to the unpaid wages, whichever is smaller…”
25. STATE YOUR REASONS FOR NOT PAYING THE AMOUNT ALLEGED BY CLAIMANT:
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
INSTRUCTIONS FOR FILING EMPLOYER WAGE CLAIM RESPONSE
Pursuant to Title 40, Oklahoma Statutes, § 165.7 and 197.7, and Oklahoma Administrative Code (OAC) 380:30-3-3, as an employer conducting
business within the State of Oklahoma, you are required to complete an Employer’s Wage Claim Response Form. Your response must include all
documentation necessary to your defense of this claim (e.g., employment policies, payroll checks, payroll records, time cards, deduction agreements,
disciplinary actions, supervisory and witness statements, etc.). Your completed response form must be returned to our office within fifteen (15) days
of the date of the accompanying notice, or fifteen (15) days of receipt of same, whichever is greater. Failure to timely return the Employer’s
Wage Claim response Form may result in a default finding for the Claimant.
I HEREBY CERTIFY that, to the best of my knowledge and belief, this is a true statement of wages, benefits, and/or deduction statements due to the
claimant from me. I understand acceptance of this response form by the Oklahoma Department of Labor does not guarantee collection.
In accordance with 12 O.S. §426,
1
I state, under penalty of perjury, under the laws of the State of Oklahoma that the foregoing wage claim response is
true and correct.
Date: ____________________________ County & City where signed: _________________________________________
Employer’s Signature: _____________________________________ Employer’s Printed Name: ___________________________________
Title: __________________________________________________
1
12 O.S. §426 Whenever, under any law of Oklahoma or under any rule, order, or requirement made pursuant to the law of Oklahoma, any matter is
required or permitted to be supported, evidenced, established, or proved by the sworn statement, declaration, verification, certificate, oath, or affidavit, in
writing of the person making the same (other than a deposition, or any oath of office, or an oath required to be taken before a specified official other than
a notary public), the matter may with like force and effect be supported, evidenced, established, or proved by the unsworn statement in writing of the
person made and signed under penalty of perjury setting forth the date and place of execution and that it is made under the laws of Oklahoma . . . The
signed statement under penalty of perjury shall constitute a legally binding assertion that the contents of the statement to which it refers are true.
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